21266 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
building Pro'en Identification PERMITNO.
B°Rd`ng Address: 21266
x.riseeoneAPPucATr5777ffPTrrA7=
O 1/ pZy CITY OF CUPERTINO-BUILDING DIVISION cm
C an onfi, Name: ue Na: APPLICATION / PERMIT to _7
BUILDINGELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL#
Arfh6e8/F-ngfneer: Lie No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PFRMITISSUANCE 1�] El ❑ ❑
LICENSED CONTRACTOR'S DECLARATION LTJ
I herebySoctle irtnthat I 0)ofDi siolicensed 3oftheesinemadn fe3 p=sr9(co and my APPWANCESRESIDENTIAL JOB DESCRIPTION
IngwltI I hon7000)of Di effect o(lheguslnevandlarofnsionaCode,and my ` {,J` `
I Is In foil( and d1M. PANELS G 1�1 t IJ `�I F-[
License Class` Lie#� f
Dale% Contractor k
nn ARCHITECT G ATION 201-1000 AMTS f !!
7. I underst#figmy pl W il W used as public mounds. OVER 1000 AMPS SQ.F7.FLOOR AREA S/SQ.FT.
qow O f i \
QIl Licensed I 1 SIGNSELECTRICAL \
OWNER-BUILDER DECLARATION
G, PA SPECIALCIICUIT/MLSC \ /
i., owing raformlWtlam31.5,Bexempt usiness
sadhe Professions
cense Law fort he '
ZO 9 t-O Following reason.(Section 703to Business and Pm pms ,s Cade:Any my it 4( 1 H 11
W coon whichr Imo rmit torowtru ilteq ire demoLLs Ir TEMP.METER ORIOLE INS(. .
�4 ty Nu pe n, prove, h,ar reps Bt
any stmcturepdorigits hat heir,licca reqs pursuant
ttothe for such
s,ofpermit e POWER DEVICES
file a signed statement that he W licensed pursuant to the provision of the
Contractor's License Law(Chapter 9(corurencing with S7000f Dii
Section )ov-
(�3 SWIMMING POOL ELECTRIC -� ` ' VALUATION
sioO the bas Rhe the alleged
d Professions Any)violation
irthat M1e f Seem therefrom and `
the Web for the allegedjctstheexemption. Any vtola civil
of Smlonf nor ri re any OUILETSSW[TC l,. FIXITJR[S 1\ 1 r A`
OQ five tort delta. $SM, athe appkcammanvil penalty of not more bun i
C, nf`i five hundred dolWrs(SM. NEW RESIDEMTAL ELECIR\ �/ SQ FT. ESV 'TYPE CONS MUCTION
r1I,as owner of the property,or my employees with wages as their sole -v
Cz6 compensation,wRl do the work and the structure b not Intended or offered for 'h
p sale(Sec.7W4,Business and Pmfessiors Code:The Contractofs License Law
�$ does not apply to an owner ofproperty who Wilds orimpeovnthereon,and 11-ana-J OCC.GROUP RFS.UNITS
who does such work himself orthraugh hbownemployees,provided that such
improvements am not Intended oroffered for sale.If,however,thebuilding or TOTAL:
Improvement bsold within oneyearo(completogthe owner-bullderwill have
tH1c.purden of proving that he did not build or Improve for purpose of sale.). QTy. PLUMBING PERMIT FEE FLOOD WhIE APN
"L as owner of the property,am exclusively contracting we.nosed PERMITISSUANCE
contractors to construct the project(Sec.7044,Illuminated Prefesslom Code:
The Contractor's License Law don not apply to an owner of Property who ALTER-DRAIN&VEM-WATER(FA)
Wilds or improves therepcts
on, and who contracts for such plowith a
rytSfactor(q licensed pursuant to the Contractor's License Law. FEE SUMMARY
BACK FLOW PROTECT.DEVICE
u I am exempt under See. B &P C for this mason
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,GOND. SANITARYY N_
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION FIX'N14F_S PER TRAP SCHOOL TAX Y N
Qf hereby a(firn that I have a certificate of consent to usure
l(-In ,or RECEIPT 0
ceniRcute ofWorkem'Compereatlon Insurance or a comfied copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FIE Y N
3800La
, b C.) _(3REC
Pdlrya G7 GAS FA.SYSTEM-OVER DING Tp
Com BUILDING DIVISION FF.KS
�C=nincdmpy Lshemby G,mis ed. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
ediBcd copy b filed with the dty Impectlon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCESEWER-SANITARY-STORM EA 200FT Date Recti t#
(chis section need not be completed If the permit W for one hundred dollars
011 W)or less.) WATER HEATER W/VENT/ELECTRENERGYFEE Y_ N_
I certify that in the performance of thework forwhich this permit Is Issued,
I shall net employ any person in any manner so as to become subject to the WATE2SYSTQd/.TREATING
Workers Compensation I,s.of California. Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ Ff. Date Recti t#
Z O NOTICETO APPLICANT.ILefler making this CenIieste of acception,you
P N should Wm
coesubject to the Workers'Compensation provlslons of the Labor TOTAL:
Code,you=at forthwith comply with such pmvislom •or this permit shall be BUILDING EE
W j deemed revoked. CM
GDN$TRDCTIDN LENDING AGENCY —V
SEISMIC FEE
CL Ihereby affirm that there b a construction lending agency for the perform- TOTAL: ELECTRIC FEE
7 Z once ofthe work for which this permit b Issued fSee 3097,Civ.C.) PLUMBING FEE
02 LL F Lender's Address
Icndcr'sNam
QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Icerify that l have read this application and state that the above Information
O W is correct.I agree to comply with all city and county ordinances and state lam PERMIT ISSUANCE FEES PAID:
} C relating tobuilding construction,and hereby authorlu represomativro ofthb
(— N my to enter upon the above-mentioned property for inspection purposes. JALTERORADDTOMECH.
Z (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
C,) against ilabilltin,jrdgmems,costs and expenses which may In any wayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against old C,Ip/In//mneyQ�enn of the granting of this permit. CONSTRUCTION TAX
AIR HANDLING UNIT(OVER 10,fA0CFM)
��
Sig�st � a o canon Date IXFFAl15T HOOD((./DIK"D CONSTRUCTION TAX PAID:
HAPARDOUS MATERIALS DISCLOSURE
Will the applicant orfutum building occupant store or handle hawrxlms HFATINGUMT(I10100,0DOBTU) Date Rece1 t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Ilealth and Safety Code Section 25532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: 35Q
❑ Yes tqNo
Will the applicant or fume,building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hawrdous air contaminants as defined by the Bay Area Air
Quality Management Dismdn7 BOILER-COMP(3H P OR 100,000 BTU) AL®,
Yn EDN.
have read the haw oua materials requirements under Chapter 6.95 of BOILER-COMP(OVER100,000 BTU) rip O
the CTlfemia I fealth&Safety Code,Sections 25505,25533 and 25534. I 1 Q `(
understand that lithe building does not currently haveatenant,that it bury NEW RESIDENTIAL MECH. SQ.Fr
G
onnityt eoavpant of the requirements which must(.rantceI ri(icateof Occupancy.kd agent Date TOTAL: ISSUEDBY
OFFICE COPY